=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720575178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CLINIC OF NJ DC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2018
-----------------------------------------------------
Last Update Date | 04/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 FORRESTAL ROAD S
-----------------------------------------------------
City | PLAINSBOROUGH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-868-6894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 549
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-0549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-868-6894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DC
-----------------------------------------------------
Name | DR. REZA POUR ALIZADEH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 612-868-6894
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00735800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------